Joint Commission Alert Shines Light on Preventing MRI Accidents, Injuries

More than 10 million MRI scans are performed each year in the United States and while most cause no harm, the inherent dangers of the process are not well known. The most common types of injuries are burns, while some of the more devastating accidents are caused by common objects that become missiles when brought into the MRI scanner's magnetic field. The Sentinel Event Alert brings the reality of risks associated with MRIs to the attention of the nation's accredited health care organizations, and offers practical solutions to avoiding injuries or deaths.

 "MRI technology represents an important advance in diagnostic medicine, but special care must be taken to protect patients," says Mark R. Chassin, M.D., M.P.P., M.P.H., president, The Joint Commission.  "The increasing use of MRI scans as a diagnostic tool, coupled with stronger MRI technology, suggests that the risk of accident and injury may increase. This Alert offers health care organizations specific steps that can be taken to keep patients safe." 

Magnetic resonance imaging, or MRI, is a diagnostic procedure that uses powerful magnet and radio waves to produce detailed images of a patient's organs and structures, without the use of X-rays or other radiation.

According to the Alert , the Food and Drug Administration (FDA) has received nearly 400 reports of MRI-related accidents over the past decade. More than 70 percent of accidents were burns, while 10 percent of injuries occurred when metal objects such as ink pens, cleaning equipment and oxygen canisters have become "missiles" when pulled into the magnetic field of the scanner.

To reduce the risk for MRI injuries to patients, The Joint Commission's Sentinel Event Alert newsletter recommends that health care organizations take the following steps:

• Restrict access to all MRI sites by creating safe zones recommended by the American College of Radiology (ACR);
• Use trained screeners to perform double checks of patients for items such as metal objects, implanted or other devices, drug delivery patches and tattoos;
• Ensure that the MRI technologist has the patient's complete and accurate medical history to ensure that the patient can be safely scanned;
• Have a specially trained staff person accompany any patients, visitors and staff into the MRI suite at all times;
• Annually educate all medical and ancillary staff who may accompany patients into the MRI suite about the risk of accidents;
• Take precautions to prevent patient burns during scanning;
• Only use fire extinguishers, oxygen tanks and other equipment that have been tested and approved for use during MRI scans (equipment that will not be attracted to the magnet);
• Manage critically ill patients who require monitoring and life-sustaining drugs to assure that their care needs are continuously met while in the MRI suite;
• Provide all MRI patients with ear plugs to diminish the loud "knocking" noise emanating from the equipment; and
• Never run a cardio-pulmonary arrest code or resuscitate a patient in the MRI room.

The warning about risks associated with MRIs is part of a series of Alerts issued by the Joint Commission. Much of the information and guidance provided in these Alerts is drawn from the Joint Commission's Sentinel Event Database, one of the nation's most comprehensive voluntary reporting systems for serious adverse events in health care. The database includes detailed information about both adverse events and their underlying causes.  Previous Alerts have addressed wrong-site surgery, medication mix-ups, health care-associated infections, and patient suicides, among others. The complete list and text of past issues of Sentinel Event Alert can be found on the Joint Commission website, http://www.jointcommission.org/.

For more patient safety solutions, visit the Joint Commission International Center for Patient Safety's free, online database of practices and interventions to prevent adverse events at http://www.jcipatientsafety.org/.